85% of pwBPD Go Into Remission

Although borderline personality disorder (BPD) has traditionally been considered a chronic and intractable disease, it is has high remission and low relapse rates, new research suggests.

Collaborative Longitudinal Personality Disorders Study

In the latest findings from the Collaborative Longitudinal Personality Disorders Study (CLPS), 85% of participants with BPD remitted during 10 years of follow-up. In addition, only 11% of these relapsed — which was significantly lower than for participants with major depressive disorder (MDD) and a group consisting of cluster C personality disorders.

However, those with BPD had significantly more social dysfunction than the other 2 groups.

"We found that [BPD] psychopathology, which has not really been adequately studied before, improves more than generally expected, and once it remits, it usually stays remitted. Not many psychiatric disorders can claim that," lead study author John G. Gunderson, MD, professor of psychiatry at Harvard Medical School and director of the McLean Center for the Treatment of Borderline Personality Disorder, Belmont, Massachusetts, told Medscape Medical News.

"It was also amazing that this was found without treatment designed specifically for this disorder. So this is really not an effect of treatment but a statement about its natural course," said Dr. Gunderson.

The study was published online April 4 in Archives of General Psychiatry.
http://archpsyc.ama-assn.org/cgi/content/full/archgenpsychiatry.2011.37

In "the only other 10-year prospective study of BPD," reported on last year by Medscape Medical News, coinvestigator Mary Zanarini, EdD, also from McLean Hospital, and colleagues found that many (but not all) patients with BPD got better with time.

Attitude Adjustment

He noted that a change in attitude is now needed because most have typically thought these are people who have chronic disease and are considered "frequent flyers" because of their many hospitalizations and emergency department visits.


"A small minority of patients that conform to that characterization has given the whole group a bad name. But for clinicians to realize most of these patients will get better makes it much less pejorative, and they can take a lot more pride in even short-term interventions that may make a lasting difference."

Psychosocial Functioning Often Remains Severely Impaired

 Dr. Gunderson pointed out, though, that psychosocial functioning for these patients often remains severely impaired.

"One of the implications of that is that we need to try to help borderline patients with their social adjustment, such as getting a job or joining social organizations. So it moves treatment away from just symptom remission to social rehabilitation."

"Despite the high prevalence of BPD in psychiatric facilities, attention to BPD remains woefully low relative to that paid to other major psychiatric disorders. Indeed, the diagnosis is underused and most mental healthcare professionals avoid or actively dislike patients with BPD," write the investigators.

In addition, past BPD research has mainly consisted of either short-term prospective or long-term retrospective studies or were conducted before 1995, they report.

In addition to using different methods, Dr. Gunderson said that his team sought to examine both the psychopathology of BPD and its associated social dysfunction.

"Their study looked at 1- or 2-year increments, whereas we looked at small intervals of change. We used measures that allowed us to look at month-by-month changes, which is important in terms of 'what predicts change' and 'what changes predict other changes,'" he explained.

"We also had comparison groups made up of specific forms of personality disorders that were matched demographically. And whereas the other study had a population of all inpatients at McLean, ours was much more demographically representative of a clinical community."

The investigators evaluated data on patients between the ages of 18 and 45 years who participated in CLPS at 1 of 19 clinical sites in the northeastern region of the United States.

For this analysis, the investigators assessed 3 subgroups of patients: those diagnosed as having BPD (n = 175), those with MDD (n = 95), and those with either avoidant personality disorder or obsessive-compulsive disorder (cluster C group, n = 312).

Criteria and changes in disorders were assessed with several measures, including the Diagnostic Interview for Personality Disorders from the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV), the Structural Clinical Interview for DSM-IV Axis I Disorders, the Longitudinal Interval Follow-up Evaluation, and the Global Assessment of Functioning (GAF) scale for up to 10 years.

High Remission, Low Relapse

Results showed that 66% of the participants completed all 10 years of follow-up, including 111 of those with BPD, 211 of those in the cluster C group, and 62 of those with MDD.

"While the overall rates of remission at 10 years were high for all 3 diagnostic study groups, the time to remission for BPD was significantly longer than for MDD (P < .001) but only minimally longer for cluster C (P = .03)," report the researchers. However, the 11% relapse rate for the group with BPD was significantly less frequent and slower than for both the MDD (P < .001) and cluster C groups (P = .008). BPD relapses "largely occurred in the first 4 years before leveling off," write the investigators, adding that only 9% of the BPD patients "remained stable disordered" (defined as meeting ≥5 disorder diagnostic criteria) at the 10-year mark. GAF scores showed severe impairment for those with BPD and "only modest albeit statistically significant" improvements. These patients also remained statistically more socially dysfunctional during the 10-year period than the other 2 groups (P < .001). Finally, criteria reductions significantly predicted subsequent improvements in GAF scores (P < .001). These results "are consistent with the theory that if patients with BPD can achieve stable supports and avoid interpersonal stressors they will remit clinically," write the investigators. "The low relapse rate suggests that during the remission process, the patients changed either psychologically, perhaps having acquired more resiliency or new adaptive skills, or situationally by attaining more supports or less stress," they add. Dr. Gunderson said there is now a real need for "more practical" BPD treatments. "We can see that they don't need to be long term and intensive to be helpful. But we do need them to be more focused on social rehabilitation." The study was funded by grants from the National Institute of Mental Health. The study authors have disclosed no relevant financial relationships. Arch Gen Psychiatry. Published online April 4, 2011. Abstract